NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Intake and output record
Time Oral intake Parenteral intake Output
0700 180 mL juice
0800 1 L 0.9% sodium chloride IV 150 mL liquid stool
1000 75 mL vancomycin
1200 240 mL tea 250 mL metronidazole IV
1500 360 mL water
1600 1300 mL urine from collection bag
Question 1 of 5
The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's net fluid balance? Record your answer using a whole number.
Correct Answer: 655 mL
Rationale: 1. Intake:
Oral: 180 + 240 + 360 = 780 mL
IV: 1000 + 75 + 250 = 1325 mL
Total Intake = 780 + 1325 = 2105 mL
2. Output:
Stool: 150 mL
Urine: 1300 mL
Total Output = 1450 mL
3. Net Balance:
2105 − 1450 = 655 mL net positive balance
Extract:
Question 2 of 5
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.
Question 3 of 5
The practical nurse collaborates with the registered nurse to perform an admission assessment on a client with Alzheimer disease. Which of the following techniques are appropriate when speaking with this client? Select all that apply.
Correct Answer: C,D,E
Rationale: Reducing background noise (
C) minimizes distractions.
Touching the shoulder (
D) gains attention non-verbally. Using clear, simple sentences (E) accommodates cognitive impairments in Alzheimer disease.
Question 4 of 5
The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?
Correct Answer: D
Rationale: A vancomycin trough of 23 mg/L is above the therapeutic range (10-20 mg/L), indicating potential toxicity. Elevated creatinine (1.5 mg/dL) suggests renal impairment, which increases the risk of vancomycin accumulation and nephrotoxicity.
Question 5 of 5
Which one of these tasks can be safely delegated to a practical nurse (PN)?
Correct Answer: C
Rationale: Provide stoma care for a client with a well functioning ostomy. The care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. This client has minimal risk of instability of the situation.